Need help with my yorkie on Vetoryol please

[resqdogs2]

Hi everyone. My name is Cheryl and I live by St. Louis, MO. My yorkie, Pebbles, who will be 13 in a couple weeks was just diagnosed right before memorial day with pituary based cushings. I have been in small dog rescue for 11 years, rescue strictly yorkies now, and seen a lot but this disease is so complicated and the more I read, the more I second guess myself, my vet, my knowledge and my decisions. I welcome feedback on the issues I am having. This is my own yorkie I have had since a puppy and she has never been sick her entire life until now. Some background (she's a spayed 10.2 lb female yorkie):

A couple weeks prior to diagnosis I had noticed she was losing weight fast (I know, not common for cushings, usually the opposite), but she was shaking uncontrollably, even when just laying there. I was getting ready to leave town and wanted to have her bloodwork retested, even though she just had a dental with full bloodwork ran in September 2015. So this May 2016, we had everything reran. Back in September, her lipase was extremely high, but that was about the only think wrong. In May, her lipase is still high at 984, her alkPh high at 440, platelets high at 707, urine gravity at 1.044.

Based on clinical signs, they wanted to do cushings testings, so she had a Low dose dex test done, for which her results were: pre - 11.9, post 3 hrs - 3.0, and post 8 hours - 5.5. She then had an ultrasound which showed bilateral enlargement of the adrenal glands, with a DX of pituitary dependent cushings.

She was prescribed 10 mg of Vetoryl once daily. She recently had her first ACTH test and the results were: pre - 5.6, post 10.7. so the medicine is working since her pre was much lower, but here's my issues.

We had the ACTH test done after 16 doses for some other reasons that have nothing to do with the medicine. She did GREAT for the first week and a half. Then started declining. All of a sudden, almost overnight, she seemed to lose most of her sight, balance, shakes again, has super sensitive hearing (if one of my other dogs barks even once she freaks out), and is panting again. The most concerning parts are the loss of sight and balance. She sometimes seems like she's not even there. her eyes will be glazed over and she will look right by me when I'm talking to her. I can see she thinks she is looking at me, but I can see she's looking a few feet to the side and has no idea I'm not there.

Here's my dilemma. With the most recent ACTH results and the symptoms showing, is she on TOO MUCH medicine? Not enough??? We can increase by 5 mg or cut back by 5 mg. What is the consensus? I know her paper results say increase, but my good friend and retired vet tech thinks I should decrease. I work during the day so can't do anything drastic because I won't be here if something happens to her. I do have cameras to watch her, but unless I gate her in a room, I also have a doggy door and she is free to go outside to potty as well and there are no outdoor cameras. I debated pulling her off when the symptoms started, but I think she needs SOME medicine. I just can't stop second guessing everything. And she is not happy right now, with no quality of life, so I need to get this straightened out. She fell last night due to her imbalance and hit her face on the ceramic water bowl. :( She also, for the first time, threw up today while I was at work. I am so incredibly concerned. I would also love to hear if anyone else has experienced imbalance, loss of sight, or this type of reaction to Vetoryl. I am leaning towards the lowered dose, but just keep second guessing.

[DoxieMama]

Welcome to you and Pebbles, Cheryl. I'm so sorry you're having to face this with her now. I don't have answers for you, but those numbers do not look like a decrease is warranted. I'd think an increase. Those symptoms don't sound like anything I've read as far as a side effect or overdose, but I don't have a lot of experience so I'll absolutely defer to those who do.

I'm curious if what you're referring to as a loss of sight is ... just a "spaced out" reaction? I ask that based on your comment that "she sometimes seems like she's not even there". Is it a loss of sight or something else? Again, I don't have answers but that is a question I'm wondering about.

I'm also curious if you had electrolytes tested when the ACTH test was done? If those are out of range, that can also effect a dosage decrease.

Hugs!
Shana

[resqdogs2]

Hi Shana. I don't think her symptoms are so much an "overdose" so much as maybe a bad reaction to the medicine. That's maybe what I'm thinking. Maybe she just can't be on that specific medicine. Idk.

Sorry I wasn't clear on her eyesight, but no, not just the spaced out. That was just another issue I guess. I was trying not to be so long winded. lol When I call her for a treat she will walk right by my outstretched hand with the treat and look for it in another place. She does the same thing with the bowls. She literally cannot see where they are at. It's very sad.

honestly not sure on the electrolytes. I just know the results of the test he told me. they came in yesterday on a sunday, so he just texted me the answers i was looking for.

As far as the dosage, i know it seems like she needs a higher dose, but her clinical signs don't show that. Initially she did better, like it was working, but now it's like it's too much maybe because she's reverting back to every sign she had before started the medicine. I just don't know. I just hesitate the increase when she's doing worse since I'm not at home during the day with her in case she has an addisonian episode. that's why it's so hard to decide.

[DoxieMama]

With those ACTH numbers, she might actually need an increase. Have you seen the manufacturer's flowchart? Maybe that will help.

http://www.dechra-us.com/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiles%2fSupportMa terialDownloads%2fus%2fUS-046-TEC.pdf

[resqdogs2]

I have. and that's why initially i was dead set on increasing by 5 mg. again, not wanting to double the dose because i'm not home during the day so wanted to do it slowly.

but now i'm second guessing myself again. thinking i should be looking at her physical condition and not just the test results. and her physical condition has deteriorated rapidly since being on the meds. so now i'm questioning the increase and debating a decrease instead.

UGH! so frustrating and so awful to watch my baby go through this. i feel so helpless. this disease is so complex. the more i read, the more i can't figure it out!

[Joan2517]

Oh, poor Pebbles! My Lena was the same thing with her sight. She just didn't see things and would rely on her nose. Cushing's is terrible and it is so hard to know what the best course of action is, but don't rush into anything.

Research, learn, question, and then decide what to do...

[DoxieMama]

She was on this dose for 16 days when that test was done. You should absolutely positively NOT increase the dose right now. Wait until the 30 day test before you decide on an increase. A decrease should be done if warranted, but don't increase until 30 days.

[judymaggie]

Hi, Cheryl--welcome to you and Pebbles! I think if I were in your place I would stop the Vetoryl altogether until Pebbles issues can be sorted out. Did the vet give you any prednisone to give Pebbles in case she had a negative reaction?

Since an ACTH wasn't done during the diagnostic phase, there is no way to know how much Pebbles' cortisol has dropped since starting on the Vetoryl. It may well be that she is reacting to a significant drop--we have seen this happen before although what you are describing does seem extreme. The relationship between Pebbles' pre and post numbers are not what indicates that she is responding to the medication. Symptom abatement would indicate that as well as future ACTH tests. You should not worry that you are doing Pebbles' harm by stopping the Vetoryl.

I am going to mention something else --there is a condition called SARDS that involves sudden onset of blindness. We have some articles on this in our "Resources" section. I am on my tablet so can't cut and paste. Hopefully, this link will work:

www.k9cushings.com/forum/showthread.php?t=213

I think you should definitely call your vet first thing in the morning and tell your vet what is going on. Please let us know how Pebbles is doing. We worry a lot!

[kanga]

Hello welcome to you Shana and Pebbles! So sorry for what's bring you here don't have any advice cause didn't experience that before but you are always in my thoughts think positive I know Pebbles will be treated soon. There's a lot of members here that had the same problem with you hope they can help you and give you some good advice and good information. I pray for Pebbles.

[judymaggie]

Cheryl--just checking in to see how Pebbles is this morning. Been worried about both of you!

[lulusmom]

Hi Cheryl and welcome to you and Pebbles.

Poor Pebbles has certainly declined a lot very quickly and we are very concerned for her welfare right now. By the way, we share more than our dogs with cushing's in common. I've been a small special needs and senior small dog rescuer for decades and Yorkies are one of the many toy breeds I've rescued and fostered over the years. I've never met a Yorkie that I didn't love. :D

Let me start by saying that the only clinical signs you mentioned are truly not commonly associated with cushing's, unless a dog has an enlarging pituitary macroadenoma. Blindness, depression, change in behavior/less friendly toward people and lack of coordination are also symptoms of a pituitary macroadenoma. I hate to say it but this is the first thing that came to my mind reading your post. I also thought about SARDS but unless a dog is super disoriented from the sudden blindness, falling over and displaying more than a little cognitive dysfunction is not typical. Dogs with SARDS usually start to show the more common symptoms of cushing's before or after the onset of blindness. The more common symptoms are excessive drinking and peeing and a humongous appetite. I don't see that Pebbles is displaying any of those symptoms but that doesn't mean you can rule out SARDS. The fact that Pebbles USG was well above normal tells me that she is not drinking and peeing in excess. Is that correct? The only way to diagnose SARDS is to have a veterinary opthamologist examine Pebbles, and I highly recommend you do that. I also recommend that you discontinue treatment with Vetoryl until Pebbles is feeling much, much better. If Pebbles does have a macroadenoma, letting the cortisol rise could actually help her.

A good number of dogs have a macroadenoma at the time of diagnoses and some of these dogs will start to show neurological signs after treatment has been initiated. It is thought that the accumulation of acth that is being dumped by the pituitary once treatment has started, facilitates the rapid growth of these large tumors. This phenomenon is called Nelson's Syndrome in humans. The only way to determine if this is what is causing Pebble's problems is an MRI which is an expensive proposition. The first line of treatment is radiation which is also expensive.

I know this is a lot to absorb but I wanted to give you as much information has possible so that you can discuss this with your vet. I will tell you up front that I used our rescue vet in California to do acth stimulation tests because it was cost effective; however, I had to train that vet on how to assess an acth stimulation tests. When I moved to a little mountain community in Arizona, I fostered for the local rescue who ran the shelter and their own vet clinic. I held a training class for both volunteer vets and vet techs on diagnosing and treating cushing's after I told them I suspected cushing's in a little old Dacshund I was fostering. They were clueless. What I'm telling you is that general practitioner vets aren't very well versed in endocrine diseases so if Pebbles is being cared for by your rescue vet or your personal gp vet, with the severity of her problems, I personally would get a referral to an internal medicine specialist asap. Both of my cushdogs had concurrent diseases and it cost me a fortune but their care was directed by a specialist who coordinated treatment with my gp vets. I have included a link below to a list of Small Animal Internal Medicine Specialist in and around St. Louis, MO.

http://find.vetspecialists.com/search_results?ttid=2&tid=9&location_value=St.+Louis%2C+MO%2C+United+States&adm_lvl_1_sn=MO&country_sn=US&location_type=locality&swlat=38.531852&nelat=38.77434909999999&swlng=-90.32051509999997&nelng=-90.16640899999999&lat=38.6270025&lng=-90.1994042&faddress=St.+Louis%2C+MO%2C+USA&place_id=ChIJ-Y7t-qm02IcRW-C7IsrqOb4

I am so sorry for the reasons that prompted you to reach out to us but I'm glad you found us. God bless you for all that you do for our furry friends and for being a great advocate for your own pup. We'll do our best to make you an even greater advocate for her, so keep us posted and ask any questions you may have.

Glynda

[molly muffin]

Hello and welcome from me also.

The other possibility which I am familiar with causing blindness is high blood pressure. My dog has this and it caused retinal bleeds, which leaves scarring and causes blindness. High cortisol can lead to high blood pressure. If your vet hasn't checked that he should and if high, get her on some sort of BP medicine.

My molly since she has lost sight, also stumbles sometimes, she occasionally misjudges things and no, she doesn't look at me either, but will turn her head once I snap my finger, or make another noise to indicate where a treat is. Smell is super increased when their sight goes and my molly's nose is like a super nose. She wiggles it when she gets going. The loss of sight bothers me more than her I think, although sometimes it confuses her.

I do think due to the vomiting I would stop the vetroyl for a bit and see how she does without it.

[judymaggie]

Cheryl -- I hope we haven't scared you away with all the information we have provided. Please let us know how Pebbles is doing.